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General NPI Number Information
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NPI Number | 1831059468
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Entity Type | Organization
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Legal Business Name | SACRED SPACE MARRIAGE THERAPY, PROF. CORP
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Dates
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Enumeration Date | 11/15/2025
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Last Update Date | 11/15/2025
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Provider Practice Location Address
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Address Line | 31526 RAILROAD CANYON RD STE 5
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City | CANYON LAKE
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State | CA
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Zip | 92587-9443
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Country | US
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Telephone | 951-219-3255
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Fax |
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Provider Business Mailing Address
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Address Line | 31724 CASINO DR
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City | LAKE ELSINORE
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State | CA
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Zip | 92530-4510
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Country | US
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Telephone | 951-219-3255
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Fax |
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Authorized Official
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Title or Position | THERAPIST
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Name | SHANNON RODRIGUEZ
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Credential | LMFT
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Telephone | 951-219-3255
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 106H00000X
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Taxonomy Name | Marriage & Family Therapist
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License Number |
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License Number State |
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